Excess mortality among essential workers in England and Wales during the COVID-19 pandemic: an updated analysis.

BACKGROUND: Excess mortality from all causes combined during the COVID-19 pandemic in England and Wales in 2020 was predominantly higher for essential workers. In 2021, the vaccination programme had begun, new SARS-CoV-2 variants were identified and different policy approaches were used. We have updated our previous analyses of excess mortality in England and Wales to include trends in excess mortality by occupation for 2021. METHODS: We estimated excess mortality for working age adults living in England and Wales by occupational group for each month in 2021 and for the year as a whole. RESULTS: During 2021, excess mortality remained higher for most groups of essential workers than for non-essential workers. It peaked in January 2021 when all-cause mortality was 44.6% higher than expected for all occupational groups combined. Excess mortality was highest for adults working in social care (86.9% higher than expected). CONCLUSION: Previously, we reported excess mortality in 2020, with this paper providing an update to include 2021 data. Excess mortality was predominantly higher for essential workers during 2021. However, unlike the first year of the pandemic, when healthcare workers experienced the highest mortality, the highest excess mortality during 2021 was experienced by social care workers.

Benefits, challenges and sustainability of digital healthcare for NHS Wales: a qualitative study.

INTRODUCTION: Digital healthcare in the UK was adopted out of necessity rather than choice during the COVID-19 pandemic. However, as we move forward, UK governments and healthcare services have acknowledged its evident benefits for patients, staff and the National Health Service (NHS), and are keen to sustain its improvements in the long term. OBJECTIVE: To understand the benefits, challenges and sustainability of a future-proof digital healthcare. DESIGN: A semi-structured interview study was conducted. SETTING: In NHS services in Wales, UK. PARTICIPANTS: With clinical and non-clinical staff across a mix of clinical specialties. OUTCOME MEASURES: Semi-structured interviews were conducted to address benefits, challenges and sustainability of a national video consulting (VC) service, and thematically coded using a quantification method of qualitative work. RESULTS: A total of 203 interviews were conducted and 3 dominant domains emerged, with 7 themes and 26 categories. LIMITATIONS: It is important to acknowledge that these findings were captured during a pandemic. CONCLUSIONS: NHS Wales has demonstrated that currently there are an equal measure of benefits and challenges to a national digital healthcare. However, with ongoing government and service support, improvement and evaluation, it has potential for a sustainable digital future, in which the benefits can outweigh the challenges.

Impact of the COVID-19 pandemic on domiciliary care workers in Wales, UK: a data linkage cohort study using the SAIL Databank.

OBJECTIVES: To quantify population health risks for domiciliary care workers (DCWs) in Wales, UK, working during the COVID-19 pandemic. DESIGN: A population-level retrospective study linking occupational registration data to anonymised electronic health records maintained by the Secure Anonymised Information Linkage Databank in a privacy-protecting trusted research environment. SETTING: Registered DCW population in Wales. PARTICIPANTS: Records for all linked DCWs from 1 March 2020 to 30 November 2021. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was confirmed COVID-19 infection; secondary outcomes included contacts for suspected COVID-19, mental health including self-harm, fit notes, respiratory infections not necessarily recorded as COVID-19, deaths involving COVID-19 and all-cause mortality. RESULTS: Confirmed and suspected COVID-19 infection rates increased over the study period to 24% by 30 November 2021. Confirmed COVID-19 varied by sex (males: 19% vs females: 24%) and age (>55 years: 19% vs <35 years: 26%) and were higher for care workers employed by local authority social services departments compared with the private sector (27% and 23%, respectively). 34% of DCWs required support for a mental health condition, with mental health-related prescribing increasing in frequency when compared with the prepandemic period. Events for self-harm increased from 0.2% to 0.4% over the study period as did the issuing of fit notes. There was no evidence to suggest a miscoding of COVID-19 infection with non-COVID-19 respiratory conditions. COVID-19-related and all-cause mortality were no greater than for the general population aged 15-64 years in Wales (0.1% and 0.034%, respectively). A comparable DCW workforce in Scotland and England would result in a comparable rate of COVID-19 infection, while the younger workforce in Northern Ireland may result in a greater infection rate. CONCLUSIONS: While initial concerns about excess mortality are alleviated, the substantial pre-existing and increased mental health burden for DCWs will require investment to provide long-term support to the sector's workforce.

Impact of the COVID-19 restrictions on the epidemiology of Cryptosporidium spp. in England and Wales, 2015-2021: a time series analysis.

Introduction. In England and Wales, cryptosporidiosis cases peak in spring and autumn, associated with zoonotic/environmental exposures (Cryptosporidium parvum, spring/autumn) and overseas travel/water-based activities (Cryptosporidium hominis, autumn). Coronavirus disease 2019 (COVID-19) restrictions prevented social mixing, overseas travel and access to venues (swimming pools/restaurants) for many months, potentially increasing environmental exposures as people sought alternative countryside activities.Hypothesis. COVID-19 restrictions reduced incidence of C. hominis cases and potentially increased incidence of C. parvum cases.Aim. To inform/strengthen surveillance programmes, we investigated the impact of COVID-19 restrictions on the epidemiology of C. hominis and C. parvum cases.Methodology. Cases were extracted from the Cryptosporidium Reference Unit (CRU) database (1 January 2015 to 31 December 2021). We defined two periods for pre- and post-COVID-19 restrictions implementation, corresponding to before and after the first UK-wide lockdown on 23 March 2020. We conducted a time series analysis, assessing differences in C. parvum and C. hominis incidence, trends and periodicity between these periods.Results. There were 21 304 cases (C. parvum=12 246; C. hominis=9058). Post-restrictions implementation incidence of C. hominis dropped by 97.5 % (95 % CI: 95.4-98.6 %; P<0.001). The decreasing incidence trend pre-restrictions was not observed post-restrictions implementation due to lack of cases. No periodicity change was observed post-restrictions implementation. There was a strong social gradient; there was a higher proportion of cases in deprived areas. For C. parvum, post-restrictions implementation incidence fell by 49.0 % (95 % CI: 38.4-58.3 %; P<0.001). There was no pre-restrictions incidence trend but an increasing incidence trend post-restrictions implementation. A periodicity change was observed post-restriction implementation, peaking 1 week earlier in spring and 2 weeks later in autumn. The social gradient was the inverse of that for C. hominis. Where recorded, 22 % of C. hominis and 8 % of C. parvum cases had travelled abroad.Conclusion. C. hominis cases almost entirely ceased post-restrictions implementation, reinforcing that foreign travel seeds infections. C. parvum incidence fell sharply but recovered post-restrictions implementation, consistent with relaxation of restrictions. Future exceedance reporting for C. hominis should exclude the post-restriction implementation period but retain it for C. parvum (except the first 6 weeks post-restrictions implementation). Infection prevention and control advice should be improved for people with gastrointestinal illness (GI) symptoms to ensure hand hygiene and swimming pool avoidance.

An external validation of the QCOVID3 risk prediction algorithm for risk of hospitalisation and death from COVID-19: An observational, prospective cohort study of 1.66m vaccinated adults in Wales, UK.

INTRODUCTION: At the start of the COVID-19 pandemic there was an urgent need to identify individuals at highest risk of severe outcomes, such as hospitalisation and death following infection. The QCOVID risk prediction algorithms emerged as key tools in facilitating this which were further developed during the second wave of the COVID-19 pandemic to identify groups of people at highest risk of severe COVID-19 related outcomes following one or two doses of vaccine. OBJECTIVES: To externally validate the QCOVID3 algorithm based on primary and secondary care records for Wales, UK. METHODS: We conducted an observational, prospective cohort based on electronic health care records for 1.66m vaccinated adults living in Wales on 8th December 2020, with follow-up until 15th June 2021. Follow-up started from day 14 post vaccination to allow the full effect of the vaccine. RESULTS: The scores produced by the QCOVID3 risk algorithm showed high levels of discrimination for both COVID-19 related deaths and hospital admissions and good calibration (Harrell C statistic: ≥ 0.828). CONCLUSION: This validation of the updated QCOVID3 risk algorithms in the adult vaccinated Welsh population has shown that the algorithms are valid for use in the Welsh population, and applicable on a population independent of the original study, which has not been previously reported. This study provides further evidence that the QCOVID algorithms can help inform public health risk management on the ongoing surveillance and intervention to manage COVID-19 related risks.

Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial.

OBJECTIVE: To assess the effectiveness of oral spironolactone for acne vulgaris in adult women. DESIGN: Pragmatic, multicentre, phase 3, double blind, randomised controlled trial. SETTING: Primary and secondary healthcare, and advertising in the community and on social media in England and Wales. PARTICIPANTS: Women (≥18 years) with facial acne for at least six months, judged to warrant oral antibiotics. INTERVENTIONS: Participants were randomly assigned (1:1) to either 50 mg/day spironolactone or matched placebo until week six, increasing to 100 mg/day spironolactone or placebo until week 24. Participants could continue using topical treatment. MAIN OUTCOME MEASURES: Primary outcome was Acne-Specific Quality of Life (Acne-QoL) symptom subscale score at week 12 (range 0-30, where higher scores reflect improved QoL). Secondary outcomes were Acne-QoL at week 24, participant self-assessed improvement; investigator's global assessment (IGA) for treatment success; and adverse reactions. RESULTS: From 5 June 2019 to 31 August 2021, 1267 women were assessed for eligibility, 410 were randomly assigned to the intervention (n=201) or control group (n=209) and 342 were included in the primary analysis (n=176 in the intervention group and n=166 in the control group). Baseline mean age was 29.2 years (standard deviation 7.2), 28 (7%) of 389 were from ethnicities other than white, with 46% mild, 40% moderate, and 13% severe acne. Mean Acne-QoL symptom scores at baseline were 13.2 (standard deviation 4.9) and at week 12 were 19.2 (6.1) for spironolactone and 12.9 (4.5) and 17.8 (5.6) for placebo (difference favouring spironolactone 1.27 (95% confidence interval 0.07 to 2.46), adjusted for baseline variables). Scores at week 24 were 21.2 (5.9) for spironolactone and 17.4 (5.8) for placebo (difference 3.45 (95% confidence interval 2.16 to 4.75), adjusted). More participants in the spironolactone group reported acne improvement than in the placebo group: no significant difference was reported at week 12 (72% v 68%, odds ratio 1.16 (95% confidence interval 0.70 to 1.91)) but significant difference was noted at week 24 (82% v 63%, 2.72 (1.50 to 4.93)). Treatment success (IGA classified) at week 12 was 31 (19%) of 168 given spironolactone and nine (6%) of 160 given placebo (5.18 (2.18 to 12.28)). Adverse reactions were slightly more common in the spironolactone group with more headaches reported (20% v 12%; p=0.02). No serious adverse reactions were reported. CONCLUSIONS: Spironolactone improved outcomes compared with placebo, with greater differences at week 24 than week 12. Spironolactone is a useful alternative to oral antibiotics for women with acne. TRIAL REGISTRATION: ISRCTN12892056.

Working and training through COVID-19 - completion of UK dental foundation training portfolios: a two-cohort study.

Introduction In March 2020, a cohort of dental foundation trainees (DFTs) were affected by the start of the COVID-19 pandemic. Then, in September 2020, a second cohort of DFTs began their training, with COVID-19 still affecting provision of primary dental care.Aims To study the effects of COVID-19 on these two cohorts by surveying Wales' dental core trainees (DCTs) who had been undertaking dental foundation training (DFTg) in 2019/20 and 2020/21.Materials and methods Following ethical approval, we conducted two online surveys for the 2019/20 and 2020/21 DFTs' cohorts. We compared and contrasted their reported completion of various DFTg curriculum components and any additional skills derived from redeployment.Results A response rate of 52% was achieved for both surveys. All participants successfully completed DFTg; although, some small differences were noted between the cohorts and their ability to fulfil all their portfolio requirements.Discussion Despite the effects of COVID-19, all DFTs were able to demonstrate completion of curriculum elements. The redeployment of three DFTs enhanced their learning. This was comparable to reports from other DFTs who were redeployed in the pandemic.Conclusions All DCTs surveyed from both cohorts successfully completed their DFTg portfolios. In some cases, additional skills were developed, which in the absence of the pandemic, may not have been the case.

Serosurveillance of SARS-CoV-2 in Welsh Blood Donors: Establishment of the surveillance system and results up to November 2022.

BackgroundIn 2020, Wales experienced some of the highest rates of confirmed COVID-19 cases in Europe. We set up a serosurveillance scheme using residual samples from blood donations to inform the pandemic response in Wales.AimTo identify changes in SARS-CoV-2 antibody seroprevalence in Wales by time, demography and location.MethodsResidual samples from blood donations made in Wales between 29 June 2020 and 20 November 2022 were tested for antibodies to the nucleocapsid antigen (anti-N) of SARS-CoV-2, resulting from natural infection. Donations made between 12 April 2021 and 20 November 2022 were also tested for antibodies to the spike antigen (anti-S) occurring as a result of natural infection and vaccination.ResultsAge-standardised seroprevalence of anti-N antibodies in donors remained stable (4.4-5.5%) until November 2020 before increasing to 16.7% by February 2021. Trends remained steady until November 2021 before increasing, peaking in November 2022 (80.2%). For anti-S, seroprevalence increased from 67.1% to 98.6% between May and September 2021, then remained above 99%. Anti-N seroprevalence was highest in younger donors and in donors living in urban South Wales. In contrast, seroprevalence of anti-S was highest in older donors and was similar across regions. No significant difference was observed by sex. Seroprevalence of anti-N antibodies was higher in Black, Asian and other minority ethnicities (self-reported) compared with White donors, with the converse observed for anti-S antibodies.ConclusionWe successfully set up long-term serological surveillance of SARS-CoV-2 using residual samples from blood donations, demonstrating variation based on age, ethnicity and location.

Dental antibiotics and referrals in general medical practice: Wales 1974-2017.

OBJECTIVES: This study aimed to explore trends and predictors for antibiotic prescriptions and referrals for patients seeking dental care at General Medical Practitioners (GMPs) over a 44-year period in Wales, UK. METHODS: This retrospective observational study analysed data from the nationwide Secure Anonymised Information Linkage Databank of visits to GMPs. Read codes associated with dental diagnoses were extracted from 1974-2017. Data were analysed using descriptive statistics, univariate and multivariable logistic regression. RESULTS: Over the 44-year period, there were a total of 160,952 antibiotic prescriptions and 2,947 referrals associated with a dental attendance. Antibiotic prescriptions were associated with living in the most deprived (OR 0.91, 95% CI 0.89-0.93) or rural (OR 0.83, 95% CI 0.82-0.84) areas, whereas referrals were associated with living in an urban area (OR 2.16, 95% CI 1.99-2.35) or rural and less deprived area (OR 1.71, 95% CI 1.26-2.33). The number of antibiotic prescriptions decreased over time whereas the number of referrals increased. CONCLUSIONS: These changes coincide with dental attendance rates at GMPs over the same period and indicate that appointment outcome and repeat patient attendance are linked. Rurality and deprivation may also influence care provided. CLINICAL SIGNIFICANCE: General medical practices are not the most appropriate place for patients seeking dental care to attend, and efforts should be made to change current practice and policy to support patients to seek care from dental practices. When patients do seek dental care from GMPs they should be encouraged to refer the patient to a dentist rather than prescribe antibiotics as an important element of national antimicrobial stewardship efforts, as well as to discourage repeat attendance.

Novel recombinant SARS-CoV-2 lineage detected through genomic surveillance in Wales, UK.

Recombination, the process whereby a segment of genetic material from one genome is inserted into another, producing a new chimeric genome, is an important evolutionary mechanism frequently observed in coronaviruses. The risks posed by recombination include the shuffling of advantageous mutations that may increase transmissibility, severity or vaccine escape. We present a genomic and epidemiological description of a new recombinant lineage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), XR, first identified in Wales. The Pathogen Genomics Unit (Public Health Wales, UK) sequences positive SARS-CoV-2 PCR tests using the ARTIC SARS-CoV-2 sequencing protocol. Recombinants were detected using an in-house pipeline and the epidemiological data analysed in R. Nosocomial cases were defined as those with samples taken after >7 days in hospital. Between February and March 2022, we identified 78 samples with highly similar genomes, comprising a BA.1-like 5' end, a BA.2-like 3' end and a BA.2-like spike protein. This signature is consistent with recombination and was defined as XR by Pangolin (PANGO v1.8). A total of 50 % of cases had a sample collected whilst in hospital and the first three cases were immunocompromised patients. The patient median age was 58 years (range: 4-95 years) and most of the patients were fully vaccinated against SARS-CoV-2 (74 % third dose/booster). Three patients died within 28 days of their sample collection date, one of whom had COVID-19 listed amongst ICD10 (International Classification of Diseases 10) coded causes of death. Our integrated system enabled real-time monitoring of recombinant SARS-CoV-2 for early detection, in order to rapidly risk assess and respond. This work highlights the importance of setting-based surveillance of recombinant SARS-CoV-2, as well as the need to monitor immunocompromised populations through repeat testing and sequencing.

Deaths at home, area-based deprivation and the effect of the Covid-19 pandemic: An analysis of mortality data across four nations.

BACKGROUND: The number and proportion of home deaths in the UK increased during the Covid-19 pandemic. It is not known whether these changes were experienced disproportionately by people from different socioeconomic groups. AIM: To examine the association between home death and socioeconomic position during the Covid-19 pandemic, and how this changed between 2019 and 2020. DESIGN: Retrospective cohort study using population-based individual-level mortality data. SETTING/PARTICIPANTS: All registered deaths in England, Wales, Scotland and Northern Ireland. The proportion of home deaths between 28th March and 31st December 2020 was compared with the same period in 2019. We used Poisson regression models to evaluate the association between decedent's area-based level of deprivation and risk of home death, as well as the interaction between deprivation and year of death, for each nation separately. RESULTS: Between the 28th March and 31st December 2020, 409,718 deaths were recorded in England, 46,372 in Scotland, 26,410 in Wales and 13,404 in Northern Ireland. All four nations showed an increase in the adjusted proportion of home deaths between 2019 and 2020, ranging from 21 to 28%. This increase was lowest for people living in the most deprived areas in all nations, with evidence of a deprivation gradient in England. CONCLUSIONS: The Covid-19 pandemic exacerbated a previously described socioeconomic inequality in place of death in the UK. Further research to understand the reasons for this change and if this inequality has been sustained is needed.